Connie N. Hess, MD, Bimal R. Shah, MD, MBA, S. Andrew Peng, MS, Laine Thomas, PhD, Matthew T. Roe, MD, MHS, Eric D. Peterson, MD, MPH

Relationship of Early Physician Follow-up and 30-Day Readmission after NSTEMI Among Older Patients

Disclosures

C.N. Hess: None. S. Peng: None. L. Thomas: None. M.T. Roe: Bristol Myers Squibb, Eli Lilly, Hoffmann-La Roche, Novartis. Astrazeneca, Helsinn Pharmaceuticals, KAI Pharmaceuticals, Merck & Co., Sanofi-Aventis, Orexigen, Regeneron. B.R. Shah: None. E.D. Peterson: Eli Lilly, Janssen Pharmaceuticals.

Background

Strategies to reduce readmissions have focused on transitions of care processes.

Prior data suggest that early physician follow-up after hospitalization for heart failure may reduce readmissions.1

Whether this strategy is effective for acute myocardial infarction (AMI) patients is unknown.

1Hernandez, AF et al. JAMA. 2010;303:1716-1722

Objectives

To characterize hospital variation in early physician follow-up after discharge for non-ST-segment elevation myocardial infarction (NSTEMI)

To examine the relationship between rates of early physician follow-up and risk of readmission

Methods: Data sources and study population Clinical data from CRUSADE registry linked with longitudinal Medicare

claims data from 2003-2006

NSTEMI pts ≥65 years surviving to hospital discharge (n= 42,568)

Patients discharged home (n= 31,789)

• Transfer to acute care facility (n= 4,474)• Transfer to skilled nursing facility/hospice (n= 6,305)

Analysis population: n= 27,852 patients at 228 sites

• Non-index admissions (n= 949)• Hospitals w/o PCI & CABG (n= 3,849)• Hospitals with < 25 pts remaining (n= 927)

Methods: Definitions and outcome

Early physician follow-up MD visit within 7 days of discharge

Primary outcome: 30-day all-cause readmission

Methods: Statistical analyses

Logistic regression with hospital as random effect to examine hospital-level early follow-up and 30-day readmission

Adjustment models:1) Patient demographic and clinical characteristics

2) #1 + hospital features (bed size, region, academic status)

3) #2 + treatment features (discharge medications, revascularization)

Variation in hospital-level early physician follow-up

0-5% 6-10% 11-15% 16-20% 21-25% 26-30% 31-35% 36-40% 41-45% 46-50% 51-55%0

10

20

30

40

50

60Median 23.3% (IQR 17.1%-29.1%)

Hospital early physician follow-up

Num

ber o

f hos

pita

ls

Results: Patient characteristicsHospital Q1

(n=6129)Hospital Q2

(n=6759)Hospital Q3

(n=7626)Hospital Q4

(n=5358)Hospital early follow-up (%) <17.8 17.8-23.2 23.3-28.9 >28.9Demographics

Age, median, y 76.0 76.0 76.0 77.0Female sex (%) 43.7 44.3 44.8 43.9Race (%)

White 89.2 87.8 82.5 83.6Black 6.1 7.3 8.5 8.3

Clinical characteristicsDiabetes Mellitus 33.4 33.2 34.5 35.5Prior MI 28.4 30.0 31.8 31.6Renal insufficiency 14.0 14.9 15.6 16.2Signs of heart failure (%) 25.8 24.3 25.3 28.0Transfer-in status (%) 31.0 31.1 24.1 15.3

In-hospital treatmentCardiac cath (%) 78.0 77.6 75.0 73.8PCI (%) 46.1 45.2 44 43.6CABG (%) 12.1 10.8 10 9.8

Hospital characteristics

Hospital Q1 (n=57)

Hospital Q2 (n=57)

Hospital Q3 (n=57)

Hospital Q4 (n=57)

RegionNortheast (%)

South (%)Midwest (%)

West (%)

22.836.836.81.8

28.131.633.37.0

17.535.128.119.3

17.524.638.615.8

Teaching hospital (%) 22.8 38.6 26.3 31.6Median # hospital beds 374.0 431.0 352.0 391.0Median length of stay (days) 5.3 5.3 5.4 5.5Transfer-in patients (%) 12.1 10.8 10 9.8

Unadjusted 30-day readmission by hospital-level early physician follow-up

Overall Hospital Q1 Hospital Q2 Hospital Q3 Hospital Q415

16

17

18

19

20

18.5118.73

17.9418.13

19.51

30-d

ay re

adm

issi

on (%

) p = 0.13

0.4 0.6 0.8 1 1.2 1.4 1.6

Model 1Quartile 2Quartile 3Quartile 4

Model 2Quartile 2Quartile 3Quartile 4

Model 3Quartile 2Quartile 3Quartile 4

Adjusted 30-day readmission by hospital-level early physician follow-up

Study limitations

Observational study - residual confounding No data regarding non-physician post-

discharge medical contacts Limited to follow-up w/in 7 days and

readmission w/in 30 days Hospital-level measure insensitive

Low overall rates of early follow-up

Conclusions

1 in 5 older NSTEMI patient readmitted within 30 days of discharge

Most patients not seen in follow-up by a physician within 7 days of discharge

Overall hospital rate of early physician follow-up low but variable

No association between early physician follow-up and 30-day readmission demonstrated

Future directions

Prospective assessment of early physician follow-up and readmission

Examination of other strategies to reduce readmission after AMI

Effectiveness of early follow-up as part of bundled strategy rather than isolated intervention

Thank you